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Medical Inspection of Schools. 



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DR. WM. L.>J ROBINS 



WASHINGTON, D. C. 



REPRINT FROM 
MEDICAL REVIEW OF REVIEWS, 

Fbbruary, 1900. 






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58168 



MEDICAL INSPECTION OF SCHOOLS.* 



BY DR. WM. L. ROBINS, WASHINGTON, D. C. 

Assistant in Nervous Diseases Clinic, Emergency- 
Hospital ; Formerly 9§ltltff, Children's 
Diseases, Emergency Hospital. 



It is a source of gratification to note 
that at least a few cities of this country 
have come to recognize the fact that it is 
our sacred duty to take every possible pre- 
caution to prevent the spread of conta- 
gious diseases among children. So long 
as the children remain at home, the re- 
sponsibility of giving this protection rests 
upon the parents. But as soon as the 
children are sent to school they are for 
the time being wards of the State, and 
should certainly have its protection. 

Dr. Jaques, of the Chicago Health 
Board, has well said : " Children at home 
are usually infected by those members of 
the family who are at work or in school ; 
hence, the prevention of the spread of 
contagion in the school or factory is one 
of the most efficient ways of protecting the 

* Read before the East Washington Citizens' 
Associalion, December 5th, 1899. 



home." It has been estimated by an au- 
thority on the subject, that 70 per cent, of 
the epidemics of contagious diseases might 
be prevented by a proper system of med- 
ical inspection of schools. 

Probably the first trial of medical school 
inspection was made in Boston in 1894 : 
" In a primary school of 40 pupils, 14 
were attacked with diphtheria in eighteen 
days. Of the 14 cases, 7 were discovered 
by the medical inspector. All suspicious 
cases were sent home to be cared for 
by their family physicians. The next 
morning every child was examined and 
cultures taken. From Thursday to the 
following Monday the class was dismissed, 
and the rooms were disinfected and 
cleaned. For ten days after his return, 
the throat of every pupil was examined by 
the inspector when the children first assem- 
bled in the morning, and no pupil who had 
been absent with any suspicious symptoms 
was allowed to return until it was proved 
by a negative culture that there could be 
no danger. As a result of these measures 
not a single case of diphtheria resulted 
beyond those known to have been infected 
at the time the epidemic was discovered." 

During further preliminary work in 
Boston, out of 8,964 pupils examined 



1,156 were found to be too ill to remain 
in school, and of the latter number 267 
were suffering from contagious and infec- 
tious diseases. 

After such conclusive proof of the value 
of medical inspection of public schools, it 
is needless to say that Boston now has a 
system of daily medical inspection — indeed, 
it is being introduced in some Euro- 
pean cities, we are told, as the " Boston 
plan." 

The Twenty-fourth Annual Report of 
the Health Board of Boston very pointedly 
says : " It has been demonstrated that there 
are not only many cases of contagious 
diseases to be found in schools, and which 
require early recognition and removal, but 
that there are large numbers of school 
children whose illness and whose disposi- 
tion by the teachers requires the decision 
of a competent physician. The work has 
disarmed all opposition and so far as we 
know has the approval of the school gov- 
ernment and the community at large, and 
has fully met the expectations of the Board 
of Health, In fourteen months out of 
16,790 pupils examined, 10,737 were 
found to be more or less sick and 2,041 
were found too ill to remain at school." 
Some of the diseases were as follows : 



CASES. 

Diphtheria 77 Scabies 47 

Scarlet fever 28 Mumps 47 

Measles 116 Whooping cough.. 33 

Chicken pox 28 Congenital syphilis & 

Pediculosis (lice) 69 

For the information of the physicians of 

Boston, the Board of Health of that city 

issued the following circular Jan. i, 1896: 

" To the Physicians of Boston : 

" Gentlemen — . . . The Board of 
Health has appointed fifty physicians who 
are known as School Inspectors and agents 
of the Board of Health. Their duties are to 
visit the public schools daily, to examine 
all sick or complaining pupils, and to 
advise the teachers concerning them. 
They will decide all questions concerning 
the school attendance of such children as 
live within the same building, but not of 
the same household, in which there is a 
case of contagious disease. Such cases 
must either be so isolated as not to 
endanger the health and liberty of other 
families, or they must be taken to a hos- 
pital. . . ." 

Then follows a list of the school inspec- 
tors with their addresses. 

Early last year. Dr. Durgin, of Boston, 
an authority on this subject said : "I am 
satisfied, after two years and seven months 



work that it would be hard to find a field 
for medical inspection and supervision 
which presents equal facilities for detect- 
ing diseases amongst congregated bodies 
or which offers more encouraging results. ^^ 

In Boston the average number of cases 
of diphtheria during the eight school 
months of the twenty years from 1877 to 
1896 inclusive, was 2,772, while for the 
four months of little or no school the 
average was 2,071. The average num- 
ber of cases of scarlet fever during the 
same period, for the school months, was 
2,779, ^""i for the four summer months 
it was only 1,191. 

The following diseases were discovered 

by the medical inspectors of Boston, 

during the year 1898 : 

Specific infectious diseases 275 

Oral and respiratory diseases 2,722 

Diseases of the ear 102 

" " eye 402 

" " skin 16,709 

Miscellaneous diseases 2,912 



Total 23,122 

The specific infectious diseases were as 

follows : 

Diphtheria 8 Mumps 31 

Scarlet fever 16 Chicken box 65 

Tuberculosis 9 Meningitis i 

Measles 26 Influenza and grip. . 20 

Whooping cough 96 Syphilis I 

Malaria 5 



Number of pupils examined in the 

schools S°)99^ 

Number recommended to be sent 

home 7>896 

Number of consultations with 
teachers (about pupils return- 
ing to school, etc.) ^t7^3 

A preliminary investigation in New York 
in 1896 demonstrated the fact that the best 
results were obtained by securing the 
absence- list of a class in which a case of 
contagious disease had occurred, and 
visiting the absent children to learn the 
causes of absence. Eighty-five famihes 
with scarlet fever or diphtheria visited 
showed 15 cases of scarlet fever and 19 
of diphtheria (in all 34 cases out of 85) in 
which the first case in the family had been 
a school child, " A statement of all known 
cases of scarlet fever in one school during 
one season showed that 13 cases out of 20 
would have remained unknown if the 
absence-list had not been investigated. Of 
these 1 3 cases, 4 di^ return to school, and, 
although in a condition to spread conta- 
gion, would have remained had they not 
been found by the medical inspector," A 
similar experience was met with in an epi- 
demic of measles. 

In New York and Boston the medical 
school inspectors are separate and distinct 
from the district inspectors of the Health 

6 



Board, but both operate under the author- 
ity of that body. 

The school inspectors' duties are, in 
short, as follows : He visits the schools of 
his district daily at the opening of the 
session, examines all pupils whom the 
teachers have found to be ill or complain- 
ing and advises the teachers concerning 
them. He makes a record of their ail- 
ments in a book kept by the principal 
and forwards daily and weekly reports to 
his chief. The rights of the family phys- 
ician are at no time encroached upon. No 
children are prescribed for by the medical 
inspector at any time, unless it be in an 
emergency when necessity compels quick 
action from a humanitarian standpoint. 
He very naturally excludes all contagious 
diseases from the school; and he sends a 
note to the family physician or a card to 
the parents of the children, stating the 
cause of exclusion. Blanks, wooden tongue 
depressors (which are destroyed after 
being used once), culture outfits, etc., 
are furnished at the oihce of the Chief 
Medical Inspector. Twenty-seven drug 
stores in the city of Boston distribute 
culture tubes to the medical inspectors 
or any other physicians who may need 
them. 



New York has 150 medical school 
inspectors who visit the schools daily. 
During the first three months of their 
work 63,812 children were examined, and 
of this number 4,183, or over six per cent., 
were excluded for contagious diseases. 

A New York authority has said that the 
amount saved in coffins for the " potter's 
field " will more than counterbalance the 
expense of medical inspection of schools 
in that city. 

In Philadelphia, where daily medical 
inspection has not yet been instituted, in 
thirteen school weeks 1,464 visits were 
made to 350 schools, with the following 
results: Skin diseases (62 of these conta- 
gious), 192; sore throat, 140; diphtheria, 
77; whooping-cough, 18; chicken pox, 13; 
parasitic diseases of the head, 66 ; scarlet 
fever, 6 ; ring worm, 60, and many others 
of minor importance. 

Through the efforts of Miss Keene, 
chairman of the Committee on Medical 
Inspection of Schools of the Public Edu- 
cation Association of Philadelphia, the 
following resolution was passed at the 
meeting of that Association November 
2ist, 1899 : 

Whereas, The contact of children at school is 
a prolific cause of transmission of contagious dis- 



ease, and, whereas, daily medical inspection of all 
ailing children has been found to be an efficient 
curb of contagion, and also to detect many other 
illnesses prejudicial to school attendance, 

Resolved, That city councils are earnestly re- 
quested to make possible a daily inspection of the 
ailing children of all public and parochial schools 
by the appropriation of $45,000 to the Bureau of 
Health for this purpose. 

Armed with this resolution, a commit- 
tee of the PubHc Education Association 
urged the Board of Health to move in 
earnest for a paid corps of 150 physicians. 
Their arguments were, first, that the paro- 
chial schools should be included, and only 
the Bureau of Health can include them ; 
second, the work is not experimental, since 
other cities have completely proven its value; 
third, a paid corps will be more permanent, 
more responsible, better organized than a 
volunteer corps can be. The item of 
$45,000 for the Bureau of Health for 
Medical Inspection of Schools is now in 
the hands of the Finance Committee of 
Councils, and those interested in the meas- 
ure have hopes of its passing. 

It is estimated that the average daily 
attendance of children in the public schools 
of Philadelphia is about 128,000, while 
that of the parochial schools is about 



28,ooo, making a grand total of 156,000 
children to be attended daily by 150 in- 
spectors. Here, as m other cities, they 
have allowed about 1,000 children, or 
three school houses to each inspector. 

Last month (November) the Board of 
Education of Chicago, at the suggestion 
of Dr. Christopher, decided to employ fifty 
physicians as daily medical inspectors. 
Dr. Christopher's plan is to bar out all 
children who have been absent from school 
four or more days, till medical experts can 
determine whether they will spread conta- 
gion among their fellow pupils. He says : 
" A child may be shghtly ill for a few days 
and then return to school apparently in 
good health, yet with the germs of the dis- 
ease still in its system, and thus endanger 
all its school fellows. Its parents may 
never suspect it is suffering from diphthe- 
ria or scarlet fever. The annual expense 
will be mider $35,000. During the sum- 
mer the council urged that all the school 
buildings be disinfected. It was estimated 
that this would cost $25,000, yet it would 
not prove so effective as my plan. For 
the danger does not lurk on the walls or in 
the clothing nearly so much as is supposed. 
It is to be found chiefly in the children 
themselves. Then bar out the children, I 



say, till it is certain they do not threaten 
their fellows." 

The Commissioner of Health of Chi- 
cago says : " The first attempt at super- 
vision of the health conditions of 200,000 
of the population at the most impression- 
ble age-period has resulted in so much 
benefit that the department will continue 
the work to the full extent of its resources. 
Our work in the medical inspection of 
school children I regard among the most 
important duties we have in hand." 

In Chicago, for the school year ended 
June 30th, 1898, 2,372 school inspec- 
tions were made mainly on physicians' 
notifications of diphtheria or scarlet fever 
among scholars in attendance. These 
led to the inspection of 2,405 homes in 
which contagious diseases were found to 
exist. In twenty-seven homes no physi- 
cian was in attendance, and these were 
furnished medical assistance by the in- 
spectors. A total of 1,272 notifications 
were sent to principals of schools, and an 
aggregate of 116,920 scholars exposed to 
infection were examined ; of this number 
5,943 were excluded from school attend- 
ance for from three to five days for fur- 
ther observation ; only nineteen of these 
developed diphtheria, and five developed 



\.,dt. 



scarlet fever. Only four medical inspect- 
ors were available for this service, and 
the aggregate expense to the city for their 
salaries while thus employed was $2,963. 

Under date of December 2d, 1899, the 
Chief Medical Inspector of Chicago writes 
me that a system of daily medical inspec- 
tion, similar to the plan now operated in 
Boston, will be instituted in that city by 
January ist, 1900. 

In St. Louis, as a preliminary trial, ten 
public schools were daily inspected, from 
October loth to December 25th, 1898 
(sixty school days), under the auspices and 
by the members of the Medical Society of 
the City Hospital Alumni. During this 
trial 1,565 pupils were examined, and of 
this number 156, or ten per cent., were 
sent home on account of some existing 
disease which was deemed dangerous either 
to the child himself or to his school fel- 
lows. About one-half of the dismissals 
for sickness were on account of infec- 
tious diseases. One pupil in 27 had 
some eye trouble. The concluding remarks 
of the report of the committee having 
in charge this trial are as follows : 
" Daily medical supervision will counter- 
act many unfortunate conditions, will 
eradicate many more ; intelligent and pains- 



taking observance of basic sanitary laws is 
both possible and feasible ; and the public 
should not condone neglect of these simple 
and wise policies. The right of the child 
to truly hygienic surroundings physical, 
in all that that implies to-day, as well as 
to truly hygienic surroundings mental, 
is paramount. Any selfish, partisan or 
otherwise narrow-minded act, that mili- 
tates against full fruition in response to 
this demand — this right — is a crime." 

Concerning the cost of medical inspec- 
tion of schools, Boston employs fifty 
inspecters at a yearly salary of $200 each. 
New York employs 150 at $300 each. 

Chicago has at present four medical 
inspectors, each of whom receives $75 
per month. Miscellaneous expenses in 
Boston amount to about $50 to $60 per 
year. Proper cards for testing eyes can 
be purchased at about $75 per thousand, 
one thousand being usually sufficient. 

Comparatively few children are ever 
well and strong after an attack of scarlet 
fever or diphtheria. These diseases prob- 
ably cause more human suffering than the 
whole category of so-called children's 
diseases combined, for the reason that they 
are so frequently followed by kidney 
di.seases, idiocy, epilepsy, and many other 

13 



conditions, thereby producing a complete 
physical and mental wreck. 

Estimating a human life in this city at 
$900 to $1,000, if the percentage of deaths 
from contagious diseases in school children 
could be reduced to, say, even a fourth, and 
the number of preventions increased in 
proportion, what an enormous saving there 
would be to the District Government after 
all the expense of medical inspection had 
been deducted, to say nothing of the sav- 
ing of suffering in homes, of insanity, idiocy, 
epilepsy and crime. An almost inestimable 
saving would be that of the cost of main- 
tenance of our institutions for the insane 
and feeble-minded. 

Let us hope that the day is not far dis- 
tant when the Capital City of the Nation 
will awaken to the importance of this ideal 
charity. 

BIBLIOGRAPHY. 

1. Twenty-fourth Annual Report of the Health 

Dept., City of Boston. 

2. Twenty-seventh Annual Report of the Health 

Dept., City of Boston. 

3. Durgin: Boston Med. and Surg. Jour., April 

9th, 1896. 

4. Reports of N. Y. Board of Health, year ending 

Dec, 1896, pp. 85-86, 359-363, 77-79. 

5. Archives of Paediatrics, August, 1896. 

6. Prescott : Annals of Gynaecol, and Psediat., 

March, 1897, ss. 354-359. 

7. Med. Review of Reviews, August 25th, 1897, 

ss. 400-401. 

14 



8. J. N. Bach: Med. News, January 8th, 1898, 

pp. 38-41. 

9. Phila. Med. Jour., Feb. 5th, 1898, p. 221. 

10. Channing: Boston Med. and Surg. Jour., 

January 13th, 1898. 

11. Biggs: Address, Internatl. Med. Magazine, 

September, 1897. 

12. Channing: Annals of Gynsecol. and Paediat. 

March, 1897. 

13. Jones, E. C: Archives ofPsediat., Dec.,'1897. 

14. Zeitschrift fur Schulgesundheitspflege, Leopold 

Voss, Hamburg. 

15. Report of Samuel Durgin, M.D., Boston, 

Annual Meeting (1897) Mass. Med. Society. 

16. Jaques : Jour, Amer. Med. Ass'n., March, 

I2th, 1898. 

17. Report of Health Dept., N. Y. City, Bureau 

of Sanitation, October, 1897 and 1899. 

18. Eaton: Pa. Med. Jour., Sept., 1897, ss. 154- 

160. 

19. Randall : Jour. Amer. Med. Ass'n, November 

i6th, 1897. 

20. Randall : Jour. Amer. Med, Ass'n, September 

7th, 1897. 

21. Risley : Report to State Med. Society on 

Exam, of Eyes of School Children, July, 
1881. 

22. Risley : Norris and OHver's Diseases of the 

Eye, V. H., ss. 353-418. 

23. Bell, Alex. Graham : Special Schools for the 

Deaf, The Deaf Child, Winter, 1898. 

24. Biennial Report Chicago Health Dep't for 

i89S-'96. 

25. Boston Med. and Surg. Jour., Dec. loth, 

1896, Editorial. 

26. Phila. Polyclinic, March 13th, 1897, Editorial 

by Randall. 

27. Lancet, May 21st, 1898, Work at Crewe, Eng. 

28. Allport : Jour. Amer. Med. Ass'n, June 4, 

1898. 

29. Keene, Miss Dora : Phila. Med. Jour., June 

1 8th, 1898. 

30. Phila. Med. Jour., April 9th, 1898, p. 623. 

31. Phila. Med. Jour., June nth, 1898, p. 1,079. 

32. Jour. Amer. Med. Ass'n, January 8th, 1898, 

Problems in Feeding School Children. 

15 



33- Jour. Amer. Med. Ass'n, February, 1898, 
School Training of Youth. 

34. Medical News, Jan, 8, 1898, 

35. Lawson : Brit. Med. Jour., June 18, 1898. 

36. Risley : Annals of Hygiene, May, 1890. 

37. Risley : Report of Vineland Training School, 

1886. 

38. Edel: Deutsch Med. Wochenschrift, 7 July, 

1898. 

39. Shattinger : St. Louis Med. Rev., April 29, 

1899. 

40. Sharpe : St. Louis Med. Rev., April 29, 1899. 

41. Keen: Public Health (Phila.), August, 1898. 

42. Arnold : Annals of Gyn. and Psed., Jan., 1898. 

43. Homan, Shapleigh & Smith, St. Louis Med. 

Rev., January 28, 1899. 

44. Baker (Cleveland) : Med. Gaz., Nov., 1897. 

45. Hippel: Ueber den einfluss Hygienischer 

Massregeln auf die Schulmyopie, St. Peters- 
burg Med. Wochenschrift, I., 1899. 

46. Schimumsky : Unterschungen des Gehoers der 

Schulkinder Monatsch f. Ohren heilk., II., 
1890. 

47. Lorenz : Die Hentige Schulbankfrage, Vienna, 

1 088. 

48. AUport : Jour. Amer. Med. Association, Jan. 

22, 1898. 

49. Allport: Review of Reviews, June, 1897. 

50. Allport: North Amer. Pract., June, 1898. 

51. Powell: Education, 1898. 

52. Stewart: Unsanitary Schools and Public 

Indifference, Forum, Vol. XX , Page 103. 



16 



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